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Offering behavioral health services in patients’ homes can make services more effective and patients more comfortable, but an already complex regulatory and reimbursement landscape for these services is set to get even more challenging.
With major Medicaid cuts under consideration in the Senate, states are increasingly likely to slash funding for home- and community-based services – further jeopardizing reimbursement for in-home behavioral health care. Home-based care advocates are pushing for sweeping regulatory reforms to safeguard access and ensure critical services keep pace with rising demand.
“Behavioral health needs are escalating nationwide – especially among Medicaid and dually eligible populations – yet reimbursement and policy frameworks have not kept pace with the demands of home-based delivery,” Kristen Palumbo, chief operating officer and chief compliance officer at Innovive Health, told Home Health Care News in an email.
Medford, Massachusetts-based Innovive provides in-home health care services for patients with multiple medical comorbidities with a behavioral health condition. Innovive offers skilled nursing designed to support mental and physical health, wound care, behavioral health care and care coordination, among other services.
Annually, one in five Americans experiences a behavioral health condition. Among Medicare beneficiaries, the rate is even higher, affecting one in four individuals.
Despite how common behavioral health concerns are, even large home health care organizations may not be fully equipped to deal with the behavioral health needs of their patients. In a recent HHCN survey, none of the five respondents reported being 100% confident that their organization could connect or provide patients with necessary behavioral health care.
In-home behavioral health care availability has fluctuated over time, according to Dallas Star, regional director of behavioral health at Bayada Home Health Care. Currently, the availability of applied behavior analysis (ABA) services has shifted in favor of in-clinic care.
“While clinic-based care offers its own benefits, a multi-setting approach, as supported by standards like those from the Council of Autism Service Providers (CASP), is crucial to meet diverse client needs,” Star said. “Organizations like BAYADA aim to bridge this gap by offering services across various settings, including homes, communities, schools, and clinics, to ensure care is delivered wherever the client needs it most.”
Pennsauken Township, New Jersey-based Bayada is a nonprofit home health care provider that offers adult skilled and non-skilled home care services, pediatric home health, hospice home care, rehabilitation at home and assistive care.
Shifts to in-clinic behavioral health care severely restrict access to care for people with profound autism, who often require home-based care or care in residential settings.
The regulations and policies home-based providers of behavioral health must follow
Organizations that do offer behavioral health care must comply with both federal regulations and state-specific policies – which can vary significantly from one state to another.
For instance, Innovive operates in Massachusetts, Colorado and Iowa, and each state has a “distinct” regulatory environment, according to Palumbo. To maintain compliance, Innovive maintains localized and centralized compliance and clinical teams in each state.
Some of the regulations Innovive must abide by include CMS Conditions of Participation, state licensure rules, Medicaid regulations, and privacy standards under HIPAA and 42 CFR Part 2.
Some states have additional requirements for home-based settings, according to Star, like an electronic visit verification (EVV).
“There is a lack of consistency across state Medicaid programs, which complicates operations for providers serving multiple states,” Star said.
Regulations vary by payer, as well as state-by-state variations. Medicaid coverage for ABA care is typically limited to individuals aged 21 and younger, Star said, and Medicare does not currently cover ABA services, limiting access to care for these beneficiaries.
The future of behavioral health in the home
Medicaid’s funding of home- and community-based services for people with mental illnesses is “lagging,” according to an article published in Health Affairs by Dennis Heaphy, researcher and policy analyst at Disability Policy Consortium in Boston, and Ellen Breslin, a principal at national health care consulting firm Health Management Associates (HMA).
Funding for home- and community-based behavioral health services is lagging because of institutional bias, Heaphy told HHCN.
“Institutional bias requires states to provide funding to institutionalization, whether it’s a nursing home or some other institution, but home- and community-based services are optional, even though it’s less expensive,” Heaphy said. “In most cases, states still opt for institutionalization because it’s basically simple or easy to do.”
Only 23 states have used 28 waivers and authorities to fund home- and community-based services for people with mental illnesses and serious emotional disturbances, while three to four times as many states have used these waivers for other populations, according to data from the Medicaid and CHIP Payment and Access Commission (MACPAC).
Already underfunded, in-home providers of behavioral health care are feeling mounting pressure from a tenuous regulatory landscape.
“Proposed Medicaid budget cuts and the current Secretary of Health’s stances on autism treatment have raised concerns among providers,” Star said. “Budget reductions could severely impact the ability to attract and retain qualified staff for ABA services, which are already stretched thin. If we pay these skilled people less, they might be forced to find jobs that pay more in other industries, like retail. This means fewer caring and talented people to help some of the most vulnerable people in our communities.”
Potential Medicaid budget cuts will not impact institutional care, according to Heaphy, but home- and community-based services stand to suffer.
“The challenge [that states are] facing right now under the new administration is that states are going to face huge cuts in their Medicaid budgets,” Heaphy said. “They can’t cut institutional care budgets, so they have to cut HCBS budgets. We’re concerned that this might disproportionately impact folks with mental health diagnoses or substance use disorder because of discriminatory practices and lack of understanding of the needs of the population.”
Advocacy efforts to improve access
To ensure long-term access to much-needed in-home behavioral health supports, providers are advocating for higher reimbursement rates and increased support for providers, all of which may be facilitated by the increased adoption of value-based reimbursement arrangements.
Innovive supports policies that foster workforce development for behavioral health professionals in community-based roles, incentivize value-based models that account for behavioral health needs and complexity and ensure parity for psychiatric and medical services.
“Policymakers have an opportunity to reframe the home as a therapeutic environment and a viable alternative to institutional care,” Palumbo said. “By recognizing the full scope of care delivered in the home – including case management and care coordination – future policy can better support patient outcomes, system sustainability, and health equity.”
Mandated reimbursement for all essential care coordination activities and adequate funding for complex cases, including adults and people with profound needs, is necessary to improve the accessibility of in-home behavioral health care, according to Star.
Star’s wish list of regulatory changes that would support access to integrated, in-home behavioral health care includes making telehealth access permanent, removing arbitrary limits like the number of years of service approved and fully funding necessary services for patients with complex needs, who may require multiple staff for a single client.
Addressing age gaps in coverage is also necessary, Star said. Medicaid often stops covering ABA services at age 21, and Medicare generally does not cover ABA services at all, leaving patients who could benefit from these services without care.
Reimbursement is also needed for services that are performed behind the scenes, Star said.
“Right now, our clinicians spend a lot of time coordinating care with other providers (like speech therapists, occupational therapists, and primary care doctors) and managing cases, but the services aren’t reimbursable,” Star said. “This makes it hard to truly integrate care and build a strong team around the patient. We need unbundled codes so they can be compensated for all the vital work they do when they’re not directly face-to-face with clients.”
Value-based arrangements can help improve access to in-home behavioral health care, according to Palumbo, but standardizing outcomes for behavioral conditions is difficult, according to Star, because each person’s goals are unique.
“You want to make sure value-based care does not increase the risk of folks being institutionalized,” Heaphy said. “What’s really important is that the fee-for-service system is broken because there is no responsibility … for the outcomes.”
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